Gastroenterology Flashcards
3 month old boy with constipation since birth, FTT, and a mildly distended abdomen with no stool on rectal exam. What would be the most appropriate next test:
a. rectal biopsy r/o hirshsprung
b. TSH
c. Sweat chloride (CF usually have meconium ileus)
d. follow up in 6 months
TSH
in this case HYPOTHYROIDISM is MORE COMMON then hirshprung, and the QUESTION is not what is the most likely diagnosis that would reveal the diagnosis (then you would pick rectal bx)
cannot assume
remember no soy if on levothryoxine
. 12 month old child who has passed 3 soft red stools in the past 12 hours. He is asymptomatic. The same thing happened 4 months ago but resolved. His Hb is now 70. Investigation?
a. Upper endoscopy
b. UGI series
c. Nuclear med scan for ectopic gastric tissue
c. Nuclear med scan for ectopic gastric tissue
6 month boy with loose stool and irribitle BF intially and then solids introduced at 4 month of age. Mucus is apparent in stool. What is most lkely DIAGNOSIS?
a- Celiac
b- Cystic fibrosis
c- Cow milk protein allergy
CMPA
BUT IF it said having FTT then you think celiac, ALSO CMPA more likely then CELIAC
CMPA does not typically cause FTT, therefore use that as a deciding factor
You see a teenager in your clinic with progressive dysphagia to solids and epigastric pain. He has been diagnosed with eosinophilic esophagitis, and a referral has been sent for allergy testing. In the meantime, what should you do?
a) Elimination diet
b) Oral fluticasone by MDI
c) Proton-pump inhibitor → treat potential GERD in the mean time until you see allergy
d) Oral Prednisone
c) Proton-pump inhibitor → treat potential GERD in the mean time until you see allergy
- A 6-week old boy has begun having loose stools, some of them blood-tinged. Exclusively breastfed. Which is most likely?
a, Meckel’s
b. Food protein-induced proctocolitis
c. Infectious colitis
Food protein-induced proctocolitis
Child with acute otitis media is taking amoxicillin and has two episodes of bloody diarrhea, Is otherwise afebrile and well. Besides discontinuing the current antibiotic, what else would you do to manage this child? a-Close follow up b PO metronidazole c PO vancomycin d PO clindamycin
a- close fu
if mild - can stop abx and follow up
moderate - tx with oral metrond
sever - oral vanco (never IV)
if toxic megacolon or sepsis then oral vanco and IV metro
Description of a 2 month old baby with colic. Tolerating breastfeeding well, normal exam. What is the best management?
- Encourage mom to continue breast feeding
- Add cows milk based formula in diet
- Add soy based formula in diet
- Simethicone
Encourage mom to continue breast feeding
As is the case for most self-resolving conditions without a known cause, counseling is the most effective treatment. However, multiple interventions with minimal effectiveness are often tried, and these often involve the gastrointestinal tract: elimination of cow milk from the breastfeeding mother’s diet, formula changes (to soy or to protein hydrolysates), or a trial of herbal tea or simethicone to decrease intestinal gas. Medications such as antispasmodics are not recommended because of the risk for side effects. Other sensory modifiers (e.g., car rides, massage, swaddling) are also attempted to provide some course of action until the expected 3- to 4-month resolution.
What is the utility behind a fecal calprotectin?
- To differentiate between functional abdominal disorder and IBD.
- To differentiate between IBS and IBD
- To determine the severity of inflammation in IBD
- To diagnose post infectious IBS
differntaite btwn IBS and IBD
Fecal calprotectin levels are elevated in inflammatory intestinal diseases, and may be useful for distinguishing inflammatory gastrointestinal disease including IBD from noninflammatory causes of chronic diarrhea (such as functional abdominal pain)
Child with 5 vomiting episodes over the last 12 months, associated with pallor, lasting 2-3 hours. Between episodes she is other well, growing and thriving, with a normal examination. What do you want to do:
- Reassure
- Refer to gastroenterology
- Neuroimaging
- Start PPI
Refer to gastroenterology
Safer to refer to gastro. Cyclic vomiting a diagnosis of exclusion.
If mention of a headache or any other worrisome neuro sx, then get neuroimaging
A 7yo boy has been complaining intermittently over the last 2 days of abdominal pain and has had non-bilious emesis. He has had several dark red mucousy stools. He is tender on palpation over the RUQ. Which imaging test would reveal the diagnosis?
- UGI
- Technetium 99 scan
- Abdo U/S
- Colonoscopy
- Abdo U/S
Child referred to you with suspicion of celiac disease. Had anti-TTG done, which was negative. What is your next step. Refer to GI Endoscopy with biopsy Anti-gliadin antibodies Measure IgA
IgA
8 year old girl with epigastric discomfort for many months, progressively getting worse and now waking her up at night time. Her father has peptic ulcer disease, and she has in fact tried his antacids with some relief. What should you do?
Reassure, she can use the antacid as needed
Treat empirically with PPI, amoxicillin, clarithromycin
Urea breath test
Esophagoduodenoscopy with biopsy
Esophagoduodenoscopy with biopsy
According to lecture: reasonable to start with antacids/PPI, since nocturnal symptoms ongoing with only some relief, need to do investigations. In children need to confirm H. pylori infection with endoscopy and biopsies before starting treatment
First line treatment = triple therapy with PPI (omeprazole) + clarithromycin + amoxicillin
Can have resistance to clarithro, guidelines are changing
8 year old boy with gastroesophageal reflux for the last 4 years, now having dysphagia on solids. Which of the following tests would reveal the diagnosis?
a. UGI
b. Upper scope + biopsy
c. Abdominal ultrasound
d. AXR
UGI
Likely prolonged reflux causing progressive stricture
13yo F in foster care has been losing weight, decreased appetite, and occasional emesis. On exam you see that she is pale and has patchy areas of hair loss. What is the most likely diagnosis?
a. Trichobezoar
b. Anorexia nervosa
c. Celiac disease
d. Lead poisoning
a. Trichobezoar
You have developed a treatment plan for a 3 year old boy with constipation including treating with PEG 3350. How long do you need to treat for?
a. 1 week
b. 3 days
c. 6 months
d. 1 year
6 months
In a patient with liver failure, which of the following is most concerning regarding need for transplantation?
a. Acute onset lethargy
b. Acute liver volume loss
c. Increase in liver enzymes
b. Acute liver volume loss
A neonate has an elevated conjugated bilirubin. What is your next step in management?
a. Liver biopsy
b. Abdominal ultrasound with Doppler
c. HIDA scan
d. Repeat liver enzymes in 2 months
AUS with dopp
r/o alagille, or biliary atresia
A 6 year old boy has recurrent vomiting episodes where he need to come to the ER and receive IV fluids. He is completely fine in between these episodes. What is the most likely diagnosis?
a. Cyclic vomiting
b. Malrotation
a. Cyclic vomiting
- A 4 year old patient presents with lethargy, bruising, hepatosplenomegaly and elevated LFT’s. He has signs of acute liver failure (this is given in the question). Which would make you most worried?
a) Sudden decrease in liver size
b) Development of asterixis
a) Sudden decrease in liver size
- Adolescent girl with scoliosis has undergone spinal surgery. She present with bilious vomiting for the last few days. What is the etiology?
a. bowel adhesions
b. superior mesenteric artery syndrome
c. malrotation with volvulus
d. pancreatitis
b. superior mesenteric artery syndrome
- Iron overdose, on dexoferoime already. Is now at 1hr post ingestion…what is the next step?
a) Endoscopy
b) Charcoal
c) WBI
d) Ipecac
WBI - whole bowel irrig
- Ipecac is no longer routinely recommended for poisoning.
- Activated charcoal is most efficacious if given within 1 hour of ingestion.
- Gastric lavage has unproven efficacy for most ingestions.
- Whole bowel irrigation is indicated for sustained-release or enteric-coated substances.
- Alkalinization of urine still considered valuable in the management of acute overdoses of salicylates, barbiturates, or tricyclic antidepressants.
- 14 yo s/p Fontan a few years ago, now diarrhea, and low albumin
a) Protein losing enteropathy
a) Protein losing enteropathy
- 5 mo Kid flexion of arms and legs, and with associated vomiting and abdo distention, sleepy after episodes. What will give diagnosis?
a) EEG
b) US abdomen
abdo US
- 15 yo boy with nocturnal diarrhea and diarrhea 3 months. No pain, tried lactose free didn’t help
a) UGI
b) Colonoscopy
c) Barium
d) Lower Scope
b) Colonoscopy
- Infant with colic
a) Try hypoallergenic milk
b) Try soy milk
c) Give probiotic
a) Try hypoallergenic milk
- 3 week old with loose stools and red blood intermixed with the stools, no FTT. What is it?
a) Anal Fissure
b) CMPA
CMPA
- Girl with facial edema, pallor. Albumin 26. Urine negative for protein. Most likely test to reveal diagnosis:
a) serum trypsinogen
b) stool alpha 1 antripsin
c) echocardiogram
d) 24 hr creatinine clearance
b) stool alpha 1 antripsin
fecal a1-antitrypsin measurement is the most useful stool marker of protein malabsorption. It is important to concomitantly measure serum a1-antitrypsin to ensure that the patient does not have a1-antitrypsin deficiency, which could result in a false-negative stool study.
8yo male. Duodenal ulcer. What is treatment? (Note: none of them listed a PPI) amox + clarithro clinda + clarithrO metronidazole + clinda bismuth subsalicylate + metronidazole
amox + clarithro
would want a PPI too
- 3 week old blood mixed with stool, has been having since 2 weeks old, normal exam, growing/thriving, formula fed
A. Anal fissure
B. Cow’s milk allergy
C. Meckel’s
Cow’s milk allergy
15yo boy presents with severe epigastric pain that worsens after eating. He has had a few episodes of non-bilious emesis. On exam he is tachycardic and has epigastric tenderness, but is otherwise stable. Blood work reveals a lipase of 1650, wbc 12.5, and normal plt, hb, lytes, renal function and ALT. What is the next best step in management?
a. NPO and IV fluids
b. Surgical consult
c. Ceftriaxone
d. IV pantoprazole
a. NPO and IV fluids
8yo boy with type 1 diabetes presents with nonspecific abdominal pain. He has had normal stools with no hematochezia. There has been a 1kg weight loss over the past 3 months. On exam he has a pruritic bullous lesions on his extensor surfaces of his arms and on his trunk. What is the most likely diagnosis?
a. Celiac disease
b. IBD
c. eosinophilic gastroenteropathy
d. parasitic infection
CELIAC
Dermatitis herpatiformis
5 month old with vomiting for 6 hours intermittently, has had 3 or 4 episodes of flexion and extension of arms and legs, drowsy after, abdomen is distended, which test would reveal diagnosis? A. EEG B. CT abdomen C. Ultrasound abdomen D. Abdominal x-ray
AUS
Intuss? - pg 1288 nelsons - most common in 3 mo to 6 yr, and abdo emergency in less then 2 y
Ultrasound sensitivity 98-100% generally and 88% for diagnosing intuss
A 3 month old male infant presents to the emergency department with a 1 month history of “spit ups” and 2 day history of projectile vomiting. His last two vomits were bilious. On exam, he looks dehydrated and unwell. His abdomen is distended, non tender, with no palpable masses. What diagnostic test would MOST likely reveal the underlying abnormality?
a. Abdominal ultrasound
b. Barium enema
c. Upper GI series
d. Abdominal X ray (anterioposterior and lateral)
a. Abdominal ultrasound
gold standard for malrotation or volvulus is upper gi. Most present within first year of life, commonly 1st month but can present with intermittent colic
You are treating a 5 year old boy for constipation. In addition to disimpaction, his mother asks you how long he will need to be treated with PEG for? 3 months 6 months Until he’s toilet trained 3 weeks
6 month
Education – of parents and child around mechanism of constipation and overflow encopresis
2) Disimpaction – with peg3350 1-1.5 g/kg/d x 3 days
3) Maintenance therapy thereafter – peg 3350 0.4-1 g/kg/d, with parents titrating to at least one soft stool daily x 6 mo
4) Behavioral modification – use of timed toileting, praise/reward, footstool for optimized position on toilet, avoiding punishment/negative reinforcement
5) Dietary modification – whole grains, fruits and veg
3 week old baby presents with poor feeding and poor weight gain. He is jaundiced and has hepatosplenomegaly. His bilirubin is 170 with conjugated 115. Which imaging would you do next? Abdominal ultrasound with dopplers HIDA scan CT abdomen MRI abdomen
Abdominal ultrasound with dopplers
If conjugated > 20% total bilirubin= cholestasis (or obstruction of bile flow).
Differential diagnosis lengthy: extrahepatic biliary atresia - most common single cause (33%).
The infant who has elevated conjugated bilirubin and cholestasis should be evaluated expeditiously to allow definitive diagnosis and surgical intervention before effective surgical drainage is precluded.
a 14 year old boy has epigastric pain, dysphagia with solids and weight loss. He is scoped and diagnosed with eosinophilic esophagitis. What management would you recommend?
Referral to Allergy for skin testing to identify potential allergens
PPI
Oral fluticasone
Oral prednisone
PPI
7 wk old baby boy who cries 5h per day and has colic, reflux with feeds; parents try soy milk, baby gets diarrhea; what do you recommend? [CPS]
a. Try 2 wks of hypoallergenic milk
b. Give PPI
c. Try probiotics
d. Try lactose free something
Try 2 wks of hypoallergenic milk
For infants with severe colic, IF concern of CMPA, an empiric time-limited (two weeks) therapeutic trial of a hypoallergenic diet could be considered
For the breastfed infant with colic where there is the relatively rare concern of a cow’s milk protein allergy, one can consider eliminating cow’s milk from the maternal diet x 2 weeks
For the bottle-fed infant with colic, rare concern CMPA, 2 week trial of an extensively hydrolyzed formula may be considered
The use of soy formulas in the treatment of infantile colic should be avoided**
Currently, evidence does not support the use of lactase in the management of infantile colic.
There is insufficient evidence to make recommendations on the use of probiotics or prebiotics
Crohn’s kid on azathioprine; present w r flank pain; stools normal. What is your dx?
a. Renal colic
b. Cholecystitis
c. Crohn’s flare
RENAL COLIC
chronic steatorrhea»_space; Fat binds to calcium, leaving oxalate free to be absorbed and deposited in the kidney, where it can form into stones. Patients w/ IBD also get uric acid stones\
Azathioprine = immunomodulatory drug used in IBD
No specific renal side effect
Most common side effects: malaise, N/V/D, leukopenia, thrombocytopenia, black box warning for malignancy, hepatotoxicity (increased transaminases), infection, myalgia, fever
7y boy with low ferritin and low hgb. Other cell lines normal, exam normal. Has been on iron treatment for 3mo with good compliance. His ferritin and hgb are still low. What is the next step?
a. Anti-TTG
b. Bone marrow
c. Upper GI
d. Upper endoscopy
a. Anti-TTG
Most common extraintestinal manifestation = iron-deficiency anemia unresponsive to iron therapy
[Nelson’s, p 1309 19th edition)
Intestinal sx in year 1-2, with FTT, vx, anorexia, muscle wasting, irritbility
Can also have osteopenia, endocrinopathy and arthritis later in life
5 years old kid w abdo pain, on u/s see intussception; has hyperpigmented macules on lips
a. Peutz jegger
b. Crohn’s
Peutz Jegher: Autosomal dominant, characterized by: [Up to date]
Multiple hamartomatous polyps in the GI tract - develop in first decade of life, 50% asymptomatic at time of diagnosis. Can present w/ obstruction caused by intussusception, occlusion caused by a polyp, pain caused by infarction, bleeding caused by ulceration
Mucocutaneous pigmentation - melanin spots, present in > 95%, most common the lips/perioral, palms/soles, buccal mucosa
Increased risk of malignancy - GI and non-GI (breast, ovary, cervix in females, sertoli cell in males)
Kid w hepatitis, which would be an indicator of function?
inr
bili
nh3
inr
A 3 week old patient is being worked up for cholestasis and is found to have a pointy chin, a broad forehead and butterfly vertebrae. Which of the following is most consistent with the diagnosis?
a. chorioretinitis
b. posterior embryotoxon
c. cataract
d. glaucoma
b. posterior embryotoxon
Alagille: part of Ddx for cholestasis, characterized by paucity of interlobular bile ducts AND:
● Chronic cholestasis (91 percent)
● Cardiac anomalies, most commonly peripheral pulmonic stenosis (85 percent)
● Butterfly vertebrae (87 percent)
● Posterior embryotoxon of the eye (88 percent)
● Dysmorphic facies, consisting of broad nasal bridge, triangular facies, and deep set eyes (95 percent)
Other manifestations: short stature, renal disease, and pancreatic insufficiency; developmental delay
AD inheritance, JAG-1 mutations (90%), NOTCH-2
- 3 month old boy with constipation sincenucle birth, FTT, and a mildly distended abdomen (RECTAL EXAM NOT DESCRIBED). What would be the most appropriate next test:
a. rectal biopsy
b. TSH
c. Sweat chloride (CF usually have meconium ileus)
d. follow up in 6 months
r/o hirshrpung with rectal bx
A 13 year old girl with intermittent cough and early morning throat pain. She also has shortness of breath with exertion. Parents comment that she has had bad breath. What would you do?
a. Upper GI
b. abdominal U/S
c. CXR
d. pH probe
ph probe
GERD
cause of malnutrition in IBD??
a. low intake of nutrients
b. Malabsorption
a - dec intake nutrient
